On January 12 this year I stood on the ruined upper level of the cathedral in Port-au-Prince, watching hundreds of Haitians congregating to remember the 230,000 people killed in the earthquake that had struck their capital exactly 12 months before. Surveying the piles of rubble, the destroyed buildings and the “temporary” camps still housing hundreds of thousands of people, it was easy to understand their frustration with the aid effort.
Also present in the capital was Paul Farmer, a doctor, anthropologist and lecturer who three decades ago began providing medical services in rural Haiti, through what became the non-governmental organisation Partners in Health. As he stresses in Haiti After the Earthquake, using a medical analogy, the latest horror was “an acute-on-chronic event” that exposed underlying failures.
Farmer recounts his conversation with Alix Lassègue, medical director of the city’s largest hospital, in the aftermath of the earthquake. Asked what he needed, Lassègue’s response was simple: “Just about everything”.
Yet for a long time, the absence of a well-supported state health sector had meant that whenever Farmer’s voluntary-funded clinics referred patients to state hospitals, he sent them with drugs, gloves, cash and even doctors and nurses. Otherwise they risked being “lost to follow-up”.
Farmer relates the hostility faced at times by relief workers to the basic problem of lack of resources for local staff. While so many dedicated Haitian doctors and nurses turned up for work within hours or days – still unpaid and grieving for their own families – international aid workers sat paralysed awaiting security, and troops turned away local patients from UN clinics. Well-paid aid “co-ordinators” flooded into Haiti but many found they were helpless without the equipment on which they were trained.
For Farmer, the tragedy intensified Haiti’s spiral of dependency. Suspicion of government corruption reinforced donors in their decision to channel funds to preferred non-governmental organisations, further fuelling the “Republic of NGOs” while undermining the state. He does not simply attack foreigners, stressing the noble efforts of many organisations and philanthropists. Several times – though with less detail than would be useful – he cites the important role of the Cuban doctors long present in Haiti.
Farmer hands the second half of his book to other eloquent participants – a decision that interrupts the narrative but just avoids lapsing into political correctness. His colleague Louise Ivers, for instance, defends US soldiers willing to get their boots dirty, unlike many “so-called humanitarian actors”. Michèle Montas-Dominique, a Haitian journalist, powerfully describes the Creole neologism bagay la, translated as “the thing”; as she writes, “we refuse to name it ‘the earthquake’, an absurd semantic shield against a possible return of the beast”.
A little too frequently, Farmer’s account falls into name-dropping, full of references to his meetings with top Haitian officials and fellow campaigners such as Bill Clinton and Jeffrey Sachs. Yet there is frustratingly little detail on the negotiations to which his privileged position gave him access. Donors might have been misguided to channel only 0.3 per cent of assistance to the government, for instance, but the authorities also refused to launch rapid and open tenders for much of the work even with what money they had.
The author describes himself as a “maximalist”, arguing for top-quality medical interventions of all types (such as use of a cholera vaccine to block the epidemic that began late last year), while “minimalists” focus on lower-tech approaches. This also reflects a criticism of Partners in Health: that it has sometimes provided “gold-plated” programmes difficult to replicate or sustain.
“We were sick of hearing the words ‘exit plan’ from disaster relief NGOs,” he writes. “How could we leave when most of the conditions that had first led us to work in the camps persisted a year after the quake?” Yet for all Farmer’s inspiring passion and humanity, without more discussion on how to exit, Haiti risks being exposed once again when the next catastrophe strikes.
Andrew Jack is the FT’s pharmaceuticals correspondent
Haiti After the Earthquake, by Paul Farmer, PublicAffairs, RRP$27.99, 456 pages